Left Thoracoscopic Approach for Convergent AF Ablation: How to Do Everything From the Same Side

Atrial fibrillation (AF) is associated with increased risk of stroke, heart failure and all-cause mortality [1]. When it comes to treating persistent AF, the Cox-Maze procedure is the gold standard. However, it presents significant morbidity and mortality rates. The classical endocardial ablation approach appears to be safer but has limited efficacy to treat long lasting persistent AF [2]. Thoracoscopic hybrid epicardial-endocardial ablation technique proved to be effective and safe to treat long lasting persistent AF patients with previous failed endocardial AF ablation [3,4].

This video illustrates the epicardial part of the convergent procedure with application of a left atrial appendage clip all through a left thoracoscopic approach.

The procedure was realized under general anesthesia with an arterial line, intravenous access and a double lumen intratracheal tube. A transesophageal echocardiogram (TOE) is performed to exclude left atrial appendage thrombus. The patient was placed in the supine position. Left arm was slightly hanging and an inflatable device was placed under the left scapula to elevate the left hemi-thorax up to 45°. Sterile external defibrillator pads were placed out of the operative field to facilitate cardioversion if necessary. Single right lung ventilation was started. Three thoracoscopic ports were placed. First, a 5-millimeter trocart was inserted through the fourth intercostal space in the anterior axillary line allowing the insertion of the thoracoscope (0°, 5mm). Working space was created using Carbon dioxide insufflation at 5-8mmHg. A second 5-millimeter port was inserted through the second intercostal space, also in the anterior axillary line. Through this port, an endoscopic pair of scissors was inserted. A third trocart, 12-millimeter, was inserted into the left pleura in the mid axillary line. The endoscopic grasper was placed in the thoracic cavity. Patient set-up is shown in Figure 1 in the video. Then the pericardium was widely opened approximately two centimeters beneath the phrenic nerve and parallel to it. Pericardial stay sutures were placed on the medial pericardium and brought through separate stab incisions for better exposure. This access creates an excellent visualization to the lateral side of the left atrial appendage (LAA), the anterior side of left pulmonary veins and the roof of the left atrium. Endoscopic instruments were retrieved and the epicardial radiofrequency suction ablation device (Episence Coagulation System, Atricure, Inc.) was then inserted through the 12mm port. The 5mm port placed in the second intercostal space was used to insert the grasper. After sectioning the ligament of Marshall, the left atrial roof and the anterior part of the left pulmonary veins were first ablated. Once this part of the ablation completed, a line from the superior left pulmonary vein to the tip of the LAA was carried out under TOE control. Then, the LAA was measured with the AtriClip sizing tool. An appropriately sized AtriClip device (AtriClip Pro2, Atricure) was used for LAA exclusion. TOE was used to confirm the complete exclusion priori to formal deployment. The clip wan be repositioned if incomplete exclusion was witnessed on TOE. All trocarts were then retrieved. The incision in the 6th intercostal space was slightly enlarged and the Subtle Cannula was brought into the thorax among with the 5 mm 0° thoracoscope. The ablation of the posterior wall and part of the right pulmonary veins was completed as usually. The ablation device and cannula were retrieved. Incisions were closed and a channeled drain is left in the left pleural space. Patients were extubated in the operating room and transferred to the intensive care unit for overnight monitoring.

References

1. Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke. 2021 Feb;16(2):217-221.
2. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020 Aug 29;ehaa612.
3. Zannis K, Alam W, Sebag FA, Folliguet T, Bars C, Fahed M, Ternacle J, Bergoend E, Hamon D, Lellouche N. The convergent procedure: a hybrid approach for long lasting persistent atrial fibrillation ablation. J Cardiovasc Surg (Torino). 2020 Jun;61(3):369-375.
4. Downs EA, Ailawadi G. Hybrid thoracoscopic epicardial and catheter-based endocardial ablation for atrial fibrillation. Multimed Man Cardiothorac Surg. 2015 Jul 22;2015:mmv015

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